=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942623772
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAWN CLACK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2014
-----------------------------------------------------
Last Update Date | 01/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 616 19TH ST SUITE 100
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31901-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-660-2600
-----------------------------------------------------
Fax | 706-494-4727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 616 19TH ST SUITE 100
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31901-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-660-2600
-----------------------------------------------------
Fax | 706-494-4727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | RPH013338
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------